Muscle invasive bladder cancer treated by transurethral resection, followed by external beam radiation and interstitial iridium-192

Perpetual role of brachytherapy in organ-sparing treatment for bladder cancer: a historical review

Brachytherapy-based radiotherapy has been applied for decades in the curative treatment for solitary, ≤ 5 cm bladder tumors. This review provides a historical perspective of this organ sparing approach.

A systematic search of the published literature between 1900 and 2019 was performed on the subject of bladder brachytherapy using PubMed, with digitally retrievable articles being supplemented with articles from the personal collection of the authors.

The articles were divided into consecutive time periods, each reflecting the impact of authors on the development of brachytherapy treatment: the time of pioneers, early innovators, modifiers, and recent innovators. Three case-controlled studies comparing brachytherapy-based organ-sparing treatment with cystectomy, demonstrated similarity between the two approaches in terms of disease-free and overall survival, whereas brachytherapy-based approach offered the advantage of at least 80% chance of bladder preservation. The overview was organized in a chronological order, starting from the evolution of brachytherapy from radium, followed by remote afterloading and dose-rate adjustments, and closing with modern era of high-dose-rate and image-guided brachytherapy. Importantly, we demonstrated how essential and beneficial for the patients is a close collaboration between radiation oncologists and urologists, and how adopting a modern surgical development, i.e. the laparoscopic implantation technique, which later became robot-assisted, contributed to the success of this multidisciplinary brachytherapy treatment.

We concluded that this highly effective brachytherapy method with very limited toxicity deserves more worldwide popularity.

Overall survival, disease-specific survival and local recurrence outcomes in patients with muscle-invasive bladder cancer treated with external beam radiotherapy and brachytherapy: a systematic review

INTRODUCTION

Neoadjuvant chemotherapy followed by radical cystectomy (RC) and pelvic lymph node dissection is the standard radical management for muscle-invasive bladder cancer (MIBC). However, major pelvic surgery is not suitable for all patients and combined modality therapy (CMT) offers an alternative for patients who want to retain their bladder. Brachytherapy (BT), as part of CMT, has been offered in selective cases of bladder cancer.

OBJECTIVES

To evaluate the clinical effectiveness of BT for solitary urinary bladder tumours in terms of survival, local recurrence (LR) rates, and adverse events.

METHODS

A systematic review was conducted using defined search terms using online databases. Articles that discussed the use of BT as part of multi-modality treatments for MIBC were included.

RESULTS

Searches returned 112 articles of which 20 were deemed suitable for analysis. In all, 15 of the 20 articles reported overall survival (OS) at 5 years, 2747 patients were at risk and 1670 were alive after 5 years (60%): seven studies reported OS at 10 years, with 817 patients at risk and 350 alive at 10 years (42%). Disease-specific survival at 5 years was reported in four studies, with 371 patients at risk and 279 alive (75%) at 5 years. LR rates were reported across all 20 studies and ranged from 0% to 32%.

CONCLUSION

Brachytherapy as part of CMT for MIBC is not a standard technique. It is an effective treatment in experienced centres for a selected patient population who wish to preserve their bladder. In such patients, CMT-BT is well tolerated with an acceptable safety profile.

Robot-assisted brachytherapy of the bladder with long distance support using video conferencing

PURPOSE

The frontline treatment for localized muscle-invasive bladder carcinoma (MIBC) is radical cystectomy. However, a significant percentage of this population is elderly with either severe co-morbidities or suboptimal general health, increasing the per- and post-operative risk when undergoing a radical cystectomy. Conservative treatment options have been implemented such as robot-assisted laparoscopic brachytherapy (RALB), a minimally invasive therapeutic approach ensuring excellent results in terms of local control, survival, and low morbidity. The treatment was supported successfully long distance using videoconferencing by an expert group from the Netherlands.

MATERIAL AND METHODS

An 81-year-old man was treated with RALB. The patient was submitted to external beam radiotherapy (EBRT) in a total dose of 40 Gy in 20 fractions. A partial cystectomy followed by implantation of three catheters along the scar and brachytherapy was completed. A total dose of 25 Gy in 10 fractions was administered with dose points calculated at 5 mm from the catheters.

RESULTS

Dose planning was characterized by an homogeneity index of 62.3% and overdose index of 19.7%. Other conformity indexes were analyzed. Patient was discharged at the fourth day after the procedure. The clinical response after 6 months was documented.

CONCLUSIONS

The previously reported good rates of tumor control and survival, and the excellent tolerance and low morbidity support RALB as a promising approach for selected groups of patients with localized MIBC. This case illustrates the ability to expand efficiently this technique, particularly among inexperienced medical teams.

Prospective Study Delivering Simultaneous Integrated High-dose Tumor Boost (≤70 Gy) With Image Guided Adaptive Radiation Therapy for Radical Treatment of Localized Muscle-Invasive Bladder Cancer

PURPOSE

Image guided adaptive radiation therapy offers individualized solutions to improve target coverage and reduce normal tissue irradiation, allowing the opportunity to increase the radiation tumor dose and spare normal bladder tissue.

METHODS AND MATERIALS

A library of 3 intensity modulated radiation therapy plans were created (small, medium, and large) from planning computed tomography (CT) scans performed at 30 and 60 minutes; treating the whole bladder to 52 Gy and the tumor to 70 Gy in 32 fractions. A "plan of the day" approach was used for treatment delivery. A post-treatment cone beam CT (CBCT) scan was acquired weekly to assess intrafraction filling and coverage.

RESULTS

A total of 18 patients completed treatment to 70 Gy. The plan and treatment for 1 patient was to 68 Gy. Also, 1 patient's plan was to 70 Gy but the patient was treated to a total dose of 65.6 Gy because dose-limiting toxicity occurred before dose escalation. A total of 734 CBCT scans were evaluated. Small, medium, and large plans were used in 36%, 48%, and 16% of cases, respectively. The mean ± standard deviation rate of intrafraction filling at the start of treatment (ie, week 1) was 4.0 ± 4.8 mL/min (range 0.1-19.4) and at end of radiation therapy (ie, week 5 or 6) was 1.1 ± 1.6 mL/min (range 0.01-7.5; P=.002). The mean D98 (dose received by 98% volume) of the tumor boost and bladder as assessed on the post-treatment CBCT scan was 97.07% ± 2.10% (range 89.0%-104%) and 99.97% ± 2.62% (range 96.4%-112.0%). At a median follow-up period of 19 months (range 4-33), no muscle-invasive recurrences had developed. Two patients experienced late toxicity (both grade 3 cystitis) at 5.3 months (now resolved) and 18 months after radiation therapy.

CONCLUSIONS

Image guided adaptive radiation therapy using intensity modulated radiation therapy to deliver a simultaneous integrated tumor boost to 70 Gy is feasible, with acceptable toxicity, and will be evaluated in a randomized trial.

Bladder function preservation with brachytherapy, external beam radiation therapy, and limited surgery in bladder cancer patients: Long-term results [corrected]

PURPOSE

To report long-term results of a bladder preservation strategy for muscle-invasive bladder cancer (MIBC) using external beam radiation therapy and brachytherapy/interstitial radiation therapy (IRT).

METHODS AND MATERIALS

Between May 1989 and October 2011, 192 selected patients with MIBC were treated with a combined regimen of preoperative external beam radiation therapy and subsequent surgical exploration with or without partial cystectomy and insertion of source carrier tubes for afterloading IRT using low dose rate and pulsed dose rate. Data for oncologic and functional outcomes were prospectively collected. The primary endpoints were local recurrence-free survival (LRFS), bladder function preservation survival, and salvage cystectomy-free survival. The endpoints were constructed according to the Kaplan-Meier method.

RESULTS

The mean follow-up period was 105.5 months. The LRFS rate was 80% and 73% at 5 and 10 years, respectively. Salvage cystectomy-free survival at 5 and 10 years was 93% and 85%. The 5- and 10-year overall survival rates were 65% and 46%, whereas cancer-specific survival at 5 and 10 years was 75% and 67%. The distant metastases-free survival rate was 76% and 69% at 5 and 10 years. Multivariate analysis revealed no independent predictors of LRFS. Radiation Therapy Oncology Group grade ≥3 late bladder and rectum toxicity were recorded in 11 patients (5.7%) and 2 patients (1%), respectively.

CONCLUSIONS

A multimodality bladder-sparing regimen using IRT offers excellent long-term oncologic outcome in selected patients with MIBC. The late toxicity rate is low, and the majority of patients preserve their functional bladder.

Trimodality treatment for bladder cancer: does modern radiotherapy improve the end results?

With the advancement in endoscopic surgery, radiation treatment planning and execution, as well as the use of new chemotherapeutic regimens, bladder conservation has evolved into a competing alternative to radical cystectomy. Trimodality treatment has the great advantage of preserving a normally functioning urinary bladder. Despite the absence of direct randomized trials comparing both modalities, trimodality treatment comprising maximal transuretheral resection of bladder tumors followed by different regimens of combined radiochemotherapy achieved comparable results to radical cystectomy in many trials. Those who did not achieve complete remission after induction radiochemotherapy were salvaged by radical cystectomy. Improving the radiotherapeutic window is a challenging issue. In radiotherapy for bladder cancer, uncertainties include set-up errors, patient movement, internal organ movement and volume changes due to bladder filling (both inter- and intrafraction). The advancement in treatment verification procedures in modern radiotherapy and the use of fiducial markers reduces set-up errors, while adaptive radiotherapy could decrease the unnecessary irradiation of normal tissues by tracking bladder volume changes. In addition, new radiotherapeutic techniques, such as intensity-modulated radiotherapy and volume-modulated radiotherapy, permit dose escalation to the target without increasing the dose to the surrounding normal tissues.

Brachytherapy versus cystectomy in solitary bladder cancer: a case control, multicentre, East-Netherlands study

PURPOSE

Comparing the outcome of surgery and brachytherapy-based radiotherapy in patients with solitary T1G3/T2 bladder tumour in, a retrospective case-control study, because efforts for a randomised clinical trial comparing these modalities have failed.

MATERIALS AND METHODS

Cystectomy group. Patients were selected using the pathological registration system (PALGA). 289 cases of TURT followed by cystectomy, indicated by a muscle--invading bladder tumour were performed in three East-Netherlands medical centres between 1991 and 2001. Out of this group 179 patients with clinical T2N0M0 bladder tumour were selected. All the consecutive files were analysed by a urologist and a radiation oncologist and 65 of those patients (mean age 63.7 years) would have been eligible for brachytherapy, based on an initial analysis: cystoscopy estimated tumour size, post-TURT pathological report, completed by CT-scan and/or, MRI-scan. A final pathological report after radical cystectomy was not considered for patients' selection. Brachytherapy group. Patients were selected using a prospective registration study aiming at determination of our treatment results. 89 Patients (mean age 68.4 years) underwent TURT followed by a course of external beam irradiation and interstitial brachytherapy from 1983 till 2005 in the Arnhem Radiotherapy Institute.

RESULTS

The median follow-up for the brachytherapy group was 5.7 years (range 0.2-21.4 years), for the cystectomy group was 5.05 years (range: 0.04-16.8 years). No difference in disease-specific survival (DSS) could be detected with a 5- and 10-year DSS of 71% and 66% in the brachytherapy group and 60% and 57% in the cystectomy group, respectively. Five-year overall survival (OS) was 57% in the brachytherapy group and 52% in the cystectomy group, however, the 10-year OS was better in the cystectomy than in the brachytherapy group (42% and 33%, respectively). This is caused by the significant age difference in favour of the cystectomy group. Cystectomy-free survival in the brachytherapy group was 70%.

CONCLUSION

Radical cystectomy is the treatment of choice for patients with muscle-invasive bladder carcinoma. However, in a selected patient population a bladder sparing treatment, i.e. a combination of transurethral tumour resection (TURT), external beam irradiation and interstitial brachytherapy, can be applied successfully. This concerns a solitary, T1G3 or T2 bladder tumour, with a diameter<5 cm.

Bladder-sparing therapy for muscle-infiltrating bladder cancer

Radical cystectomy is the treatment of choice for nonmetastatic, muscle-infiltrating bladder cancer. Several researchers have proposed the use of a bladder-sparing approach in carefully selected patients. Strict selection criteria and close follow-up are needed for bladder-preservation protocols. Although repeated transurethral resection of bladder tumors or partial cystectomy might be offered to high-risk patients, combined protocols with transurethral resection of bladder tumors and chemotherapy, with or without additional radiotherapy, seem to provide the best results, with 5-year survival rates of about 50%. Even if the chance of preserving the bladder is appealing, and despite evidence of some promising results, these protocols should still be considered investigative because, as yet, there are no randomized trials available that compare cystectomy with bladder-sparing surgery.

Radiotherapy for Bladder Cancer

The radiotherapy panel met to develop international consensus about the optimal use of radiotherapy, alone or in combination with surgery and chemotherapy, in the radical treatment of patients with bladder cancer. A consensus meeting of experts in the treatment of bladder cancer was convened by the Société Internationale d'Urologie (SIU). The radiotherapy committee, which had international representation from 6 countries, performed a critical review of the English-language literature and developed evidence-based guidelines for the use of radiotherapy in the treatment of patients with bladder cancer. The strength of the evidence supporting each recommendation was ranked according to a 4-point scale. Consensus statements were developed that address (1) the effectiveness of radiotherapy in the treatment of bladder cancer, (2) the most appropriate patients for curative treatment with radiotherapy, (3) the optimal method of delivery of radiotherapy, (4) the best radiation prescription for treating bladder cancer, and (5) optimal management of the patient's condition after radiotherapy has been provided. Radiotherapy is effective treatment for selected patients with bladder cancer; it produces long-term disease control with preservation of normal bladder function. Modern radiotherapy treatment techniques offer the potential to improve cure rates and reduce adverse effects. All patients in whom the condition is newly diagnosed should be assessed in a multidisciplinary setting, where the relative merits of surgery, radiotherapy, and chemotherapy can be considered on an individual basis with the aim of optimizing overall outcomes.

Radical radiotherapy for invasive bladder cancer: What dose and fractionation schedule to choose?

PURPOSE

To establish the alpha/beta ratio of bladder cancer from different radiotherapy schedules reported in the literature and provide guidelines for the design of new treatment schemes.

METHODS AND MATERIALS

Ten external beam radiotherapy (EBRT) and five brachytherapy schedules were selected. The biologically effective dose (BED) of each schedule was calculated. Logistic modeling was used to describe the relationship between 3-year local control (LC3y) and BED.

RESULTS

The estimated alpha/beta ratio was 13 Gy (95% confidence interval [CI], 2.5-69 Gy) for EBRT and 24 Gy (95% CI, 1.3-460 Gy) for EBRT and brachytherapy combined. There is evidence for an overall dose-response relationship. After an increase in total dose of 10 Gy, the odds of LC3y increase by a factor of 1.44 (95% CI, 1.23-1.70) for EBRT and 1.47 (95% CI, 1.25-1.72) for the data sets of EBRT and brachytherapy combined.

CONCLUSION

With the clinical data currently available, a reliable estimation of the alpha/beta ratio for bladder cancer is not feasible. It seems reasonable to use a conventional alpha/beta ratio of 10-15 Gy. Dose escalation could significantly increase local control. There is no evidence to support short overall treatment times or large fraction sizes in radiotherapy for bladder cancer.

Survival after Bladder-Preservation with Brachytherapy versus Radical Cystectomy; A Single Institution Experience

OBJECTIVE

To evaluate the long-term survival following brachytherapy and following cystectomy of patients with invasive bladder cancer treated in our institution.

PATIENTS AND METHODS

Between 1988 and 2000 108 patients with solitary, organ confined T1-T2 invasive bladder cancer of < or = 5 cm were treated with a transurethral resection, and a course of external beam radiotherapy (30 Gy) followed by 40 Gy brachytherapy. The overall and disease specific survival rates of these patients are compared with those of 77 patients with T1-T2 invasive bladder cancer treated with cystectomy between 1988-2003.

RESULTS

The 5/10 year overall survival rates were 62%/50% after brachytherapy and 67%/58% after cystectomy (p = 0.67). The 5/10 year disease specific survival rates were 73%/67% after brachytherapy and 72%/72% after cystectomy (p = 0.28). When adjusted for age, multiplicity, T-stage, N-stage and grade, the 5/10 year overall survival rates were 65%/53% after brachytherapy and 62%/51% after cystectomy, respectively. The adjusted disease specific survival rates were 75%/70% after brachytherapy and 66%/66% after cystectomy.

CONCLUSIONS

This study does not provide evidence regarding survival against the use of bladder preservation with brachytherapy for patients with solitary, T1-T2 invasive bladder cancer of < or = 5 cm diameter, seeking bladder-sparing alternatives to radical cystectomy.

Organ preservation in invasive bladder cancer: Brachytherapy, an alternative to cystectomy and combined modality treatment?

PURPOSE

To evaluate our long-term results of bladder preservation with brachytherapy in the treatment of bladder cancer.

METHODS AND MATERIALS

Between 1987 and 2000, 108 patients with T1-G3 and T2-T3a stages of bladder cancer were treated with a transurethral resection (TUR) and a course of external beam radiotherapy (30 Gy in 15 fractions) followed by brachytherapy (40 Gy). All tumors were solitary lesions with a diameter < or =5 cm. Median follow-up was 54 months (range, 1-178 months).

RESULTS

The 5-year and 10-year overall survival rates were 62% and 50%, respectively. The 5-year and 10-year disease-specific survival rates were 73% and 67%, respectively. The actuarial local control rate was 73% at 5 and 73% at 10 years, respectively. The 5-year and 10-year disease-specific survival rates for patients with a preserved bladder were 68% and 59%, respectively. Of all long-term surviving patients, 90% preserved their native bladders. The treatment was well tolerated. Acute toxicity was mild. Two patients experienced serious late toxicity: 1 patient developed a persisting vesicocutaneous fistula and the other a stricture of the urethra and ureters.

CONCLUSION

For patients with solitary, organ confined invasive bladder cancer < or =5 cm, bladder preservation with brachytherapy is an excellent alternative to radical cystectomy and combined modality treatment.

Salvage cystectomy after failure of interstitial radiotherapy and external beam radiotherapy for bladder cancer

OBJECTIVE

To evaluate the long-term results of salvage cystectomy after interstitial radiotherapy (IRT) and external beam radiotherapy (EBRT) for transitional cell carcinoma, and to assess the morbidity and functional results of the different urinary diversions used.

PATIENTS AND METHODS

The records of 27 patients treated with salvage cystectomy in one institution between 1988 and 2003 were retrospectively analysed.

RESULTS

Salvage cystectomy was used after failure of IRT in 14 or EBRT in 13 patients, with a 3- and 5-year survival probability of 46% (95% confidence interval 26-65) and 33 (11-54)%. The 5-year overall survival after cystectomy was 54% after IRT and 14% after EBRT (P = 0.12). Tumour category, response to radiation, American Society of Anesthesiology score, and complete tumour resection had a significant influence on survival. Five of seven patients with incomplete resection died because of local disease, with a median survival of 5 months. There was clinical understaging after radiotherapy in 41% of patients. Nine patients had an orthotopic neobladder, with complete day- and night-time continence in eight and four, respectively. All patients but one had good voiding function. There were early complications in two and late complications in six patients (for Bricker, seven of 14 and none; for Indiana, none of four and two of four). The duration of hospitalization was not influenced by the type of diversion. Erectile function was maintained in four of six patients after a sexuality-preserving cystectomy and neobladder.

CONCLUSIONS

Salvage cystectomy can be performed with acceptable morbidity using any type of urinary diversion. Understaging after radiotherapy is common, but preoperative selection needs improving. A very significant factor for an adverse outcome and death from local tumour recurrence was incomplete resection, suggesting that salvage cystectomy should only be attempted if complete resection is probable.

Bladder-conserving surgery and interstitial brachytherapy for lymph node negative transitional cell carcinoma of the urinary bladder: results of a 28-year single institution experience

BACKGROUND AND PURPOSE

We retrospectively analyzed results for lymph node negative transitional cell carcinoma of the bladder treated with brachytherapy.

PATIENTS AND METHODS

From 1975-2002, 58 patients received preoperative external irradiation, partial cystectomy (in 69%), iliac node dissection, and iridium-192. Pathologic stage was: 10 pT1, 41 pT2, and 7 pT3. A median total brachytherapy dose of 60 Gy was delivered to the tumor bed.

RESULTS

Mean follow-up was 76 months (range, 0.5-296). Tumor stage significantly impacted cause-specific and disease-free survival (P=0.02). Eight pT1 patients were free of disease and 2 died of other cause. For pT2 patients, 5-year cause-specific and overall survival rates were, respectively, 70% (CI 95%: 53-87) and 60% (CI 95%: 43-77). Three pT3 patients died of cancer. For the pT2 patients, the probability of 5-year local control was 65% (CI 95%: 47-83) and being alive without disease with a functional bladder, 50% (CI 95%: 33-67). Previous transurethral resection (TUR) increased the bladder relapse risk among pT2 patients (P=0.03). Twelve patients had severe acute complications and 5 had severe late effects. A high dose of external irradiation increased risk of late complications (P=0.01). Most complications occurred in patients treated before 1985.

CONCLUSIONS

Highly select patients presenting with pT2 tumors less than 5 cm with no history of previous TUR may be successfully treated with low-dose external irradiation, limited partial cystectomy, and interstitial brachytherapy. High-risk pT1 patients may also benefit. Postoperative complications and late side effects are minimized with modern management. We recommend lifelong cystoscopic surveillance, with prompt surgical salvage for recurrence.

Low-dose-rate brachytherapy is superior to high-dose-rate brachytherapy for bladder cancer

PURPOSE

To determine the efficacy and safety of a high-dose-rate (HDR) brachytherapy schedule in the treatment of bladder cancer and to investigate the impact of different values of repair half-times and alpha/beta ratios on the design of the HDR schedule.

METHODS AND MATERIALS

Between 2000 and 2002, 40 patients with T1G3 and T2 bladder carcinoma were treated with 30 Gy external beam radiotherapy followed by interstitial HDR brachytherapy to a total dose of 32 Gy in 10 sessions of 3.2-Gy fractions in two fractions daily with a 6-h interfraction interval. The local control rate and toxicity were compared with a historical group of 108 patients treated with 30 Gy external beam radiotherapy followed by 40-Gy interstitial low-dose-rate (LDR) brachytherapy. The HDR schedule was designed to be biologically equivalent to the previously used LDR schedule with the linear-quadratic model, including incomplete mono-exponential repair.

RESULTS

The local control rate at 2 years was 72% for HDR vs. 88% for LDR brachytherapy (p = 0.04). In the HDR group, 5 of 30 evaluable patients encountered serious late toxicity: 4 patients developed a contracted bladder with inadequate capacity (<100 mL), and 1 patient required cystectomy because of a painful ulcer at the implant site. In the LDR group, only 2 of 84 assessable patients developed serious late toxicity. One patient developed a persisting vesicocutaneous fistula and the other a urethral stricture due to fibrosis. The difference in observed late toxicity for HDR vs. LDR was statistically significant (p = 0.005). The increased late toxicity with the HDR schedule compared with the LDR schedule suggests a short repair half-time of 0.5-1 h for late-responding normal bladder tissue.

CONCLUSION

Local control of HDR brachytherapy for bladder cancer was disappointing and late toxicity unexpectedly high. The increase in late toxicity suggested a short repair half-time of 0.5-1 h for late-responding normal bladder tissue, which would not support HDR brachytherapy in the treatment of bladder cancer. The analysis demonstrated that the calculation of equivalent HDR schedules on the basis of the LDR schedules used in clinical practice might be hazardous.

Saving bladders with brachytherapy: implantation technique and results

PURPOSE

To analyze and report the treatment results of brachytherapy for solitary bladder cancer in the Arnhem Radiotherapy Institute.

METHODS AND MATERIALS

Between January 1983 and October 1998, 63 patients with a solitary bladder tumor were treated with a combination of transurethral resection, external beam radiotherapy (EBRT), and interstitial radiotherapy. The indications for bladder-conserving treatment were tumor < or =5 cm, T1G3 (n = 14), T2G2 (n = 8), T2G3 (n = 37), and T3a (n = 4). The prescribed implant dose was either 55 Gy (range 50-65 Gy) in combination with small pelvis external beam RT, 3-4 fractions of 3.5 Gy (n = 58), or 30 Gy in combination with 20 fractions of 2 Gy external beam radiotherapy (n = 5). Brachytherapy was performed with 2-8 137Cs needles until 1995 (n = 48) and 2-5 afterloading catheters (192Ir) since 1996 (n = 15). Follow-up cystoscopies were performed at 3-month intervals during the first 2 years, then every 6 months for 3 years, and annually after the fifth year. The median follow-up was 4.9 years.

RESULTS

Twenty patients developed local recurrences, of which 6 were "true in-implant recurrences," 12 were in second bladder locations, and 2 were urethral recurrences. All recurrences developed within 2.5 years after treatment. Of these 20 patients, 13 underwent cystectomy: 6 stayed disease-free, 1 died of postoperative complications, 2 developed regional metastases, and 4 developed distant metastases. The 5-year disease-specific survival rate was 80% for patients with Stage T1 and 60% for those with Stage T2 disease. The local control rate was 70% in the whole patient population and 80% after salvage cystectomy. Forty-four bladders were saved. Acute complications were seen in 14 patients, and no significant late complications occurred.

CONCLUSION

Using this treatment technique, a high cure rate with conservation of the bladder and only minor toxicity can be obtained in a selected patient population having a solitary tumor < or =5 cm.

Distressful symptoms after radical radiotherapy for urinary bladder cancer

BACKGROUND

Radical radiotherapy for muscle-invasive urinary bladder cancer can sterilize the tumour with preserved organ function. Here we studied symptoms, symptom distress and trade-off among long-term survivors and compared figures to those of population controls and patients who had undergone cystectomy.

MATERIALS AND METHODS

We identified 71 patients who had had urinary bladder cancer treated with radical radiotherapy before 1995. For comparison, 325 patients treated with radical cystectomy and urostomy, continent or non-continent, during the same period and 460 individuals randomly selected from the general population were included. Information was collected by means of an anonymously answered postal questionnaire to avoid investigator-related bias.

RESULTS

Answers were obtained from 58 (82%) radiated patients, 251 (85%) cystectomized patients and 310 (71%) population controls. Of the radiated patients, 74% reported little or no distress from symptoms from the urinary tract, 38% had had intercourse the previous month and 57% (men) reported they had ejaculated. Among the cystectomized patients, 13% had had intercourse and 0% (men) had ejaculated. Moderate or much distress from symptoms from the gastrointestinal tract was reported by 32% of the radiated patients, 24% of the cystectomized patients and 9% of the population controls. After radical radiotherapy, 46% of the patients were willing to accept some risk of decreased survival to become symptom-free.

CONCLUSIONS

About 3/4 of these long-term survivors after radical radiotherapy for bladder cancer had a functioning urinary bladder with little or no distress from the urinary tract. The prevalence of sexual dysfunction was lower than after cystectomy and the prevalence of distress from the gastrointestinal tract was comparable.

Radiotherapy for carcinoma of the bladder: a review

Carcinoma of the bladder (CaB) is a common and important tumor in North America and Western Europe. There has been a steady increase in the incidence of CaB during the past 25 years in both of these regions with a simultaneous decrease in the mortality rates. The decrease in mortality is primarily due to an earlier diagnosis and the availability of more effective therapeutic interventions resulting from major advances in surgery and a wide use of multimodality bladder preservation therapy.The use of radiotherapy in the management of muscle-invasive CaB has undergone a major evolution. External beam radiotherapy alone is used infrequently in carefully selected patients. The same applies to the use of preoperative irradiation. Brachytherapy alone or combined with external beam radiotherapy has been used successfully in Europe but is used infrequently in North America. External beam radiotherapy is an essential component of a multimodality therapy consisting of cytoreductive surgery via transurethral resection of a bladder tumor followed by a planned combination of radiotherapy and chemotherapy. The outcomes of this bladder preservation therapy are similar to those reported in a like patient population treated with radical cystectomy. The main benefit of conservatively treated patients is functioning bladder in about 50% of those receiving conservative therapy. Radiotherapy alone or in a combination with chemotherapy remains an important and effective palliative therapy for patients with recurrent and/or metastatic CaB. Current research efforts are directed toward a better identification of important pretreatment risk factors predicting failure thus helping in a more optimal selection of patients who would benefit most from radical cystectomy or from the application of bladder preservation therapy.

Bladder-sparing treatment of invasive bladder cancer

BACKGROUND

Radical cystectomy with pelvic lymph node dissection is the standard treatment for patients with invasive bladder cancer. However, many alternative techniques to spare the bladder have been investigated.

METHODS

We review the experience reported in the literature on bladder-sparing techniques, including transurethral resection, chemotherapy, and radiation for muscle-invasive disease.

RESULTS

Most comparative studies indicate that local recurrence and survival outcomes for bladder-sparing approaches are inferior to those from radical cystectomy to control muscle-invasive bladder cancer.

CONCLUSIONS

Although molecular biologic techniques may have the capacity to identify a subgroup who may benefit from a bladder-sparing approach, cystectomy is normally required for optimal results.

Radiotherapy in bladder cancer

In the present review, we have evaluated the outcome of radiotherapy in patients with bladder cancer. The exact value of radical radiotherapy is difficult to establish because changes in treatment techniques and selection of patients have biased the results. The 5-year survival rates are reported to be 35-71% in T1 tumors, 27-59% in T2 tumors, 10-38% in T3 tumors and 0-16% in T4 tumors. Several other factors, like performance status and hemoglobin level, are important for the outcome. Morbidity of radical radiotherapy depends on several treatment and patient related factors, but 50-75% experience acute intestinal or urological symptoms and 10-20% may develop severe late toxicity, depending on the kind of registration. The importance of field size or overall treatment time cannot be established from available data. Hyperfractionation with dose escalation has proven effective in one study. Preoperative radiotherapy with cystectomy has not proven better than cystectomy alone or better than radiotherapy alone. The addition of systemic chemotherapy has increased disease-free survival, but has not significantly reduced the rate of distant metastases or improved overall survival. Presently, the standard radiation regimen is a conventional dose and fractionation schedule to a total dose of 60-66 Gy with a three- or four-field technique covering the bladder and tumor. The efficacy of additional irradiation of regional lymph nodes is questionable. New treatment possibilities with advanced techniques of radiotherapy, hyperfractionation and dose escalation and/or the addition of systemic chemotherapy may improve outcome. These options should be further explored in clinical trials.